Pacemaker lead insertion sites contribute to abnormalities of myocardial function and histopathology

BACKGROUND

Ventricular pacing can cause myocardial dysfunction, but how lead anchoring to the myocardium affects function has not been studied.

OBJECTIVE

The purpose of this study was to evaluate patterns of regional and global ventricular function in patients with a ventricular lead using cine cardiac computed tomography (CCT) and histology.

METHODS

This was a single-center retrospective study with 2 groups of patients with a ventricular lead: (1) those who underwent cine CCT from September 2020 to June 2021 and (2) those whose cardiac specimen was analyzed histologically. Regional wall motion abnormalities on CCT were assessed in relation to lead characteristics.

RESULTS

For the CCT group, 122 ventricular lead insertion sites were analyzed in 43 patients (47% female; median age 19 years; range 3-57 years). Regional wall motion abnormalities were present at 51 of 122 lead insertion sites (42%) in 23 of 43 patients (53%). The prevalence of a lead insertion-associated regional wall motion abnormality was higher with active pacing (55% vs 18%; P < .001). Patients with lead insertion-associated regional wall motion abnormalities had a lower systemic ventricular ejection fraction (median 38% vs 53%; P < .001) than did those without regional wall motion abnormalities. For the histology group, 3 patients with 10 epicardial lead insertion sites were studied. Myocardial compression, fibrosis, and calcifications were commonly present directly under active leads.

CONCLUSION

Lead insertion site-associated regional wall motion abnormalities are common and associated with systemic ventricular dysfunction. Histopathological alterations including myocardial compression, fibrosis, and calcifications beneath active leads may explain this finding.

Acute impact of atrial fibrillation on pacemaker lead-induced tricuspid regurgitation: Case report

We report a case of worsening lead-induced tricuspid regurgitation (TR) after new-onset atrial fibrillation (AF) evaluated using three-dimensional (3D) transthoracic echocardiography (TTE) from admission through TR improvement. An 84-year-old man experienced worsening lead-induced TR with new-onset AF, acutely resulting in low output syndrome. Less invasive interventions, such as rhythm control therapy and diuretics administration worked effectively. However, 3DTTE revealed consistent restricted motion of the septal leaflet with lead impingement. Right heart dilatation due to AF and worsened TR led to incomplete closure of other leaflets and tricuspid annular dilatation, which caused further deterioration of the TR. According to the course of our case, new-onset AF can cause acute worsening of lead-induced TR and low output syndrome in patients with cardiac implantable electronic devices (CIED). Our findings emphasize the importance of understanding the TR etiology in patients with CIED, which may prevent unnecessary CIED lead extraction.

Learning objective

Lead-induced tricuspid regurgitation (TR) can acutely deteriorate after new onset of atrial fibrillation (AF). AF-induced deterioration of TR may not depend on restricted motion of a leaflet with lead impingement but on incomplete closure of other leaflets caused by right heart and tricuspid annular dilatation. Rhythm control therapy and diuretics administration may improve AF-induced deterioration of lead-induced TR, and should be considered before performing invasive lead extractions.

Bow-and-arrow sign on point-of-care ultrasound for diagnosis of pacemaker lead-induced heart perforation: A case report and literature review

BACKGROUND

Pacemaker lead-induced heart perforation is a rare but life-threatening complication of pacemaker implantation, and timely diagnosis remains a challenge for clinicians. Here, we report a case of pacemaker lead-induced cardiac perforation rapidly diagnosed by a “bow-and-arrow” sign on point-of-care ultrasound (POCUS).

CASE SUMMARY

A 74-year-old Chinese woman who had undergone permanent pacemaker implantation 26 d before suddenly developed severe dyspnea, chest pain, and hypotension. The patient had received emergency laparotomy for an incarcerated groin hernia and was transferred to the intensive care unit 6 d before. Computed tomography was not available due to unstable hemodynamic status, so POCUS was performed at the bedside and revealed severe pericardial effusion and cardiac tamponade. Subsequent pericardiocentesis yielded a large volume of bloody pericardial fluid. Further POCUS by an ultrasonographist revealed a unique “bow-and-arrow” sign indicating right ventricular (RV) apex perforation by the pacemaker lead, which facilitated the rapid diagnosis of lead perforation. Given the persistent drainage of pericardial bleeding, urgent off-pump open chest surgery was performed to repair the perforation. However, the patient died of shock and multiple organ dysfunction syndrome within 24 h post-surgery. In addition, we also performed a literature review on the sonographic features of RV apex perforation by lead.

CONCLUSION

POCUS enables the early diagnosis of pacemaker lead perforation at the bedside. A step-wise ultrasonographic approach and the “bow-and-arrow” sign on POCUS are helpful for rapid diagnosis of lead perforation.

Left hemothorax resulting from delayed right ventricular apical pacing lead perforation without hemopericardium, a case report

INTRODUCTION AND IMPORTANCE

Right ventricular pacemaker lead perforation is a rare but well documented complication of pacemaker implantation. Lead perforation can cause an array of symptoms ranging from none to hemodynamic instability and tamponade. In previously reported cases, lead perforation has always been able to be confirmed by imaging, with computed tomography (CT) scan considered to be the gold standard diagnostic imaging modality.

CASE PRESENTATION

An 80-year-old male underwent uncomplicated implantation of a dual chamber pacemaker for sick sinus syndrome as an outpatient. Thirty-nine days later, the patient presented to the emergency department complaining of new-onset, left-sided, pleuritic chest pain. He was found to have unilateral hemothorax and abnormal pacemaker lead interrogation. Pacemaker lead perforation was suspected but not confirmed with imaging. Lead perforation was only identified after surgical exploration.

CLINICAL DISCUSSION

This patient had multiple risk factors for pacemaker lead perforation. However, imaging, including CT scan was unable to confirm perforation. The presence of an otherwise unexplained left hemothorax strongly suggested that surgical intervention was indicated. The lead perforation was subsequently confirmed with subxiphoid exploration of the pericardial space. The mechanism of lead perforation resulting in hemothorax in this case is not straight forward, as no direct communication between the pericardial and pleural spaces was identified. However, previously described visceral pericardial self-sealing may contribute to the small pericardial accumulation described herein.

CONCLUSION

This patient's presentation and clinical course underscore the importance of maintaining a high index of suspicion for pacemaker lead perforation despite a lack of confirmation with imaging.

Right ventricular perforation, pneumothorax, and a pneumatocele by a pacemaker lead: a case report

Background

Perforation of the right ventricle by a pacemaker lead is a rare and potentially life-threatening complication. We present a patient who developed right ventricular perforation, pneumothorax, and a cyst and underwent partial lung resection.

Case presentation

A 94-year-old woman was diagnosed with sick sinus syndrome and underwent a dual-chamber permanent pacemaker implantation. The next day, pacing failed and chest radiography showed that the right ventricular lead was outside the cardiac silhouette. Computed tomography revealed that the lead had perforated the right ventricular apex, causing a left-sided pneumothorax and a cystic lesion at the site of pulmonary injury by the pacemaker lead. The patient underwent lung resection and a right ventricular lead extraction. Pathological analysis revealed the cystic lesion to be an acute pneumatocele.

Conclusions

Pneumothorax and pneumatocele associated with right ventricular pacemaker lead perforation is extremely rare. In our case, a radical surgical intervention provided an excellent outcome.

Electrical abnormalities with St. Jude/Abbott pacing leads: A systematic review and meta-analysis

BACKGROUND

Although there is a paucity of contemporary data on pacemaker lead survival rates, small studies suggest that some leads may have higher malfunction rates than do others.

OBJECTIVE

The purpose of this study was to determine the malfunction rates of current pacemaker leads.

METHODS

A meta-analysis including studies that examined the non-implant-related lead malfunction rates of current commercially available active fixation pacemaker leads was performed. An electronic search of MEDLINE/PubMed, Scopus, and Embase was performed. DerSimonian and Laird random effects models were used.

RESULTS

Eight studies with a total of 14,579 leads were included. Abbott accounted for 10,838 (74%), Medtronic 2510 (17%), Boston Scientific 849 (6%), and MicroPort 382 (3%) leads. The weighted mean follow-up period was 3.6 years. Lead abnormalities occurred in 5.0% of all leads, 6.1% of Abbott leads, 1.1% of Medtronic, 1.4% of Boston Scientific, and 5.5% of MicroPort. The most common lead abnormality was lead noise with normal impedance. Abbott leads were associated with an increased risk of abnormalities (relative risk [RR] 7.81; 95% confidence interval [CI] 3.21-19.04), reprogramming (RR 7.95; 95% CI 3.55-17.82), and lead revision or extraction (RR 8.91; 95% CI 3.36-23.60). Abbott leads connected to an Abbott generator had the highest abnormality rate (8.0%) followed by Abbott leads connected to a non-Abbott generator (4.7%) and non-Abbott leads connected to an Abbott generator (0.4%).

CONCLUSIONS

Abbott leads are associated with an increased risk of abnormalities compared with leads of other manufacturers, primarily manifesting as lead noise with normal impedance, and are associated with an increased risk of lead reprogramming and lead revision or extraction.

Left ventricular pacemaker wire through patent foramen ovale

A 53-year-old male status post pacemaker placement three months prior for sinus bradycardia presented with worsening dyspnea, holosystolic murmur, and a ventricular-paced right bundle branch block on electrocardiogram. Transesophageal echocardiography demonstrated a pacer wire in the right atrium coursing into the left atrium and ventricle through an undiagnosed patent foramen ovale. The patient underwent surgical repair and repositioning of the pacemaker lead without complication. Although rare, it should be suspected after recent lead placement.

Percutaneous management of atrium and lung perforation: A case report

BACKGROUND

Cardiac perforation by a transvenous lead is an uncommon but serious complication. Delayed perforation, defined as migration and perforation of an implanted lead at least 1 mo after implantation, is exceedingly rare and prone to underdiagnosis, and its optimal management is currently unclear. We report an uneventful transvenous extraction of an active fixation lead that led to delayed perforation of the right atrium, pericardium, and lung, disclosed 2 mo after implantation.

CASE SUMMARY

A 61-year-old woman with atrial lead perforation was transferred to our center. She had a dual-chamber pacemaker with active fixation leads implanted 8 mo previously. At 2 mo after implantation, she complained of chest pain and hemoptysis. Chest computed tomography revealed atrial lead migration into the lung. No pericardial or pleural effusion was detected. She underwent transvenous lead extraction in the electrophysiology room with surgical backup. The percutaneous subxiphoid pericardial puncture was performed first, and a pigtail catheter was left in the pericardial sac throughout the procedure. Then, a new active fixation lead was implanted at a different site with less tension. After the active screw was retracted, the culprit atrial lead was explanted successfully with simple traction. There were no complications during or after the procedure. The patient recovered well and follow-up was uneventful.

CONCLUSION

Percutaneous management of perforated active fixation lead outside the pericardial sac under surgical backup is safe and effective.

Pacemaker lead as an iatrogenic cause of right heart failure: Case report

Technical advances in health care have improved patient survival and quality of life, but are not devoid of complications. We present the case of a 74-year-old woman with a history of hypertensive heart disease with preserved systolic function, atrial fibrillation and dyslipidemia. She had a DDDR pacemaker implanted in 2005 due to symptomatic complete atrioventricular block. The patient reported progressive fatigue, weakness, ascites with abdominal discomfort, and lower limb edema, accompanied by non-specific hepatic cholestasis on biochemical testing. Abdominal ultrasound revealed homogeneous hepatomegaly and dilatation of the inferior vena cava and upper hepatic veins, suggestive of congestive hepatopathy. Echocardiography revealed tricuspid regurgitation progressively worsening over the previous four years and dilatation and progressive dysfunction of the right ventricle, with preserved left ventricular function. The transesophageal echocardiogram revealed severe tricuspid regurgitation with flail septal leaflet and marked dilatation of the tricuspid annulus due to mechanical interference of the pacemaker lead, which was adhering to the septal leaflet. Minimally invasive surgical treatment was performed with partial resection of the leaflet, placement of a tricuspid annuloplasty ring and replacement of the pacemaker lead. Regression of the congestive symptoms was observed, and the postoperative echocardiogram showed the tricuspid annuloplasty ring with no evidence of stenosis and only slightly dilated right chambers with moderate pulmonary hypertension. Six months after the procedure, the patient suffered an acute neurological event and died.

Transfemoral extraction of pacemaker and implantable cardioverter defibrillator leads using Needle's Eye Snare: a single-center experience of more than 900 leads

The femoral approach with the Needle's Eye Snare (NES) is often used for bailout after failure of the superior approach for transvenous lead extraction (TLE). The safety and efficacy of the NES as a first-line tool for TLE remain unclear. The medical records of patients who underwent TLE via the femoral approach utilizing the NES from May 2014 to June 2019 in Peking University People's Hospital were retrospectively reviewed. Nine hundred and eighty-five leads were extracted in 492 patients (369 men; mean age 72.8 ± 29.0 years). The median (range) number of leads extracted per patient was 2 (1-6). The mean indwelling time of all extracted leads was 112.6 ± 52.0 months. The complete procedure success rate, clinical success rate, and failure rate were 94.1% (463/492), 97.8% (481/492), and 1.1% (11/492), respectively. Major complications including death occurred in nine patients (1.9%), of whom eight developed cardiac tamponade. Among these eight patients, emergency pericardiocentesis followed by rescue surgical repair if necessary was successful in 6 (75.0%) and failed in 2 (25.0%). No significant differences were found in the clinical success rate or major complications rate between patients with pacemakers and implantable cardioverter defibrillators, or between patients with infected and uninfected leads. A femoral approach with the NES is safe and effective for TLE of both pacing and defibrillator leads and could be considered a first-line approach. Cardiac tamponade was the most frequent cardiovascular complication. A strategy of emergency pericardiocentesis followed by a rescue surgical approach seems to be reasonable technique to treat a cardiac tamponade.

A technique to prevent recurrence after the repair of pacemaker lead-induced tricuspid regurgitation

This article describes how to repair pacemaker lead-induced tricuspid regurgitation without removing the pacing leads. Our technique can eliminate the lead contact with the tricuspid leaflets and the tricuspid apparatus and is effective in preventing recurrence.

Safety and Efficacy of Transvenous Lead Extraction With a High-Frequency Excimer Laser - A Single Center Experience

BACKGROUND

Transvenous lead extractions have been performed using 40-Hz laser sheaths. Recently, a new 80-Hz laser sheath became available, but only a few reports have compared the effectiveness of the 40- and 80-Hz laser sheaths. Methods and Results: This study included 215 patients. Lead extractions using only laser sheaths were analyzed. The clinical characteristics, extraction parameters, and extraction tools were evaluated. The procedures were performed with 40-Hz sheaths in 150 patients (group 1: 270 leads) and 80-Hz sheaths in 65 (group 2: 99 leads). No statistically significant differences were observed in the clinical parameters except for sex. The mean implant duration was 95.3±86.0 and 78.2±56.8 months in groups 1 and 2, respectively (P=0.07). The respective mean laser time and number of laser pulses were 48.5±52.1 and 48.1±56.1 s (P=0.96) and 2,035.0±2,384.0 and 3,955.1±2,339.3 pulses (P<0.0001). Complete removal was achieved for 97.4% of the leads and in 98.0% in both groups (P=0.38). Major complications occurred in 2.0% and 3.1% of the patients in groups 1 and 2, respectively (P=0.94).

CONCLUSIONS

Transvenous lead extraction using high-frequency laser sheaths was as highly successful as with low-frequency laser sheaths in Japanese patients.

Pacemaker lead endocarditis with hiccups (Kalayci)

BACKGROUND

Lead-related infections that might develop after pacemaker implantation associated with high mortality and morbidity rates are challenging to manage and pose high-cost. Patients with lead-related infections usually present with fever, chills and fatigue and the treatment can be challenging unless the implant system is extracted.

CASE PRESENTATION

A 66-year old male patient who underwent dual chamber pacemaker and implantable cardioverter defibrillator was admitted to the emergency service with a six-week history of complaints of hiccups and fever. After a detailed investigation, lead-related infective endocarditis was the diagnosis. The patient was initiated on antibiotic therapy and lead extraction was performed.

CONCLUSIONS

Patients with signs of infection who underwent pacemaker implantation may present with atypical symptoms such as hiccup. In these cases, imaging, particularly echocardiography, should be performed as soon as possible and the localization of the pacemaker leads and signs of infective endocarditis should be investigated.

Tricuspid Clip: Step-by-Step and Clinical Data

Symptomatic severe tricuspid regurgitation (TR), if untreated, carries a dismal prognosis. These patients are at very high risk for surgical repair or replacement and transcatheter options to treat TR are emerging. More than 300 transcatheter tricuspid repairs with the MitraClip system have been performed worldwide with promising results. The TriClip system, with the MitraClip NT delivered via a dedicated tricuspid steerable guide catheter, is currently under investigation. This article describes the step-by-step technique on using the MitraClip system to perform transcatheter tricuspid repair using echocardiographic and fluoroscopic guidance. The latest data on worldwide experience with tricuspid clipping are also discussed.

Medial subclavicular musculotendinous complex and insulation break: Rare cause of late pacemaker lead malfunction

Insulation break in a permanent pacemaker lead is a rare long-term complication. We describe an elderly male with a VVIR pacemaker, who presented with an episode of presyncope more than 3 years after the initial implantation procedure, attributed to insulation break possibly caused by lead entrapment in components of the medial subclavicular musculotendinous complex (MSMC) and repeated compressive damage over time during ipsilateral arm movement requiring lead replacement. The differential diagnosis of a clinical presentation when pacing stimuli are present with failure to capture and the role of the MSMC in causing lead damage late after implantation are discussed.

Overcoming the challenge of venous occlusion for lead implantation

Vein stenosis or occlusion is a frequent finding in patients with previously-implanted transvenous leads. This editorial describes the different techniques that may be used to overcome this hurdle in case a new lead needs to be implanted, and discusses two case reports in this issue of the journal.

Ratchet-traction effect: an underdiagnosed mechanism of pacing lead dislodgement

Pacing lead dislodgement contributes substantially, to the list of causes of early pacemaker failure. Reel's syndrome is a rare cause of pacemaker failure, resulting from the dislodging of pacing electrodes by manipulation of the pulse generator by the patient. We describe here an intriguing case of pacemaker lead dislodgement by a novel and frequently underdiagnosed mechanism that mimicked the fluoroscopic diagnosis of reel's syndrome.

Pacemaker lead induced inferior vena caval thrombosis leading to portal hypertension

Inferior vena caval thrombosis is an unusual complication of permanent pacemaker implantation. The clinical presentation due to thrombosis depends on the site of thrombus. We have described here a rare case of pacemaker lead associated thrombosis of inferior vena cava, its diagnostic work up and briefly reviewed the existing literature of this uncommon complication.

A novel way of repair of insulation breaks during pacemaker generator replacement

Minor abrasions can occur while mobilising old lead during pacemaker generator replacement necesittating placement of additional lead adding to the financial burden and junk in heart. We describe a novel way of repair of old pacemaker lead preventing additional lead placement.